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640 James Drive, Richardson Texas 75080
Tel: 972-231-5351 Fax: 972-231-2269 Toll Free:
800-776-5267 |
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Legal Name of Firm |
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Mailing Address: State, City, Zip |
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Shipping Address: State, City, Zip |
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Phone
Fax |
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Credit Limit Desired |
( ) Sole Owner
( ) Partnership
( ) Corporation |
Principal Stockholders, Owners, Partners
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Name |
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Address |
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City, State, Zip |
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Driver's License No.
State |
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Social Security No.
Birthdate |
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Name |
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Address |
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City, State, Zip |
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Driver's License
No.
State |
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Social Security No.
Birthdate |
Bank Reference
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Name |
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Address |
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City, State, Zip |
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Phone
Fax |
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Account Number
Contact Person |
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Supplier References (Please List
Three)
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Name |
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Address |
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City, State, Zip |
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Phone
Fax |
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Account Number
Contact Person |
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Name |
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Address |
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City, State, Zip |
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Phone
Fax |
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Account Number
Contact Person |
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Name |
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Address |
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City, State, Zip |
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Phone
Fax |
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Account Number
Contact Person |
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The undersigned hereby
agrees to the terms and conditions of sale, applicable at the time of
order, and further accepts personal responsibility for payment of monies
due EVS for same. If at any time, for any reason, the undersigned is unable
to pay for purchases when due, without prejudice to the right of EVS to
immediate payment per terms of sales, the undersigned agrees to pay and
authorizes EVS to bill the account a service charge monthly up to the
maximum rate allowed by law. In the event it becomes necessary for EVS
to incur collection cost of institute suit to collect any amount due on
the account, the undersigned promises to pay such additional collection
costs, charges and expenses, including reasonable attorney's fees if the
account is placed for collection.
I clearly understand that the information given is subject to audit and
review by EVS, further that the credit extended under this application
is subject to revocation.
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Authorized Signature and Title
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Please Print
Name
Date |
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